202.661.5700 www.acscan.org July 27, 2015
Sylvia Burwell Secretary
Department of Health and Human Services Attention: CMS-2390-P
Room 445-G
Hubert H. Humphrey Building 200 Independence Avenue, SW Washington, D.C. 20201
Re: Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability; Proposed Rules 80 Fed. Reg. 31098 (June 1, 2015)
Dear Secretary Burwell:
The American Cancer Society Cancer Action Network (ACS CAN) appreciates the opportunity to comment on the proposed rule implementing changes to the Medicaid Managed Care and Children’s Health Insurance Program (CHIP) Comprehensive Quality Strategies. ACS CAN, the nonprofit,
nonpartisan advocacy affiliate of the American Cancer Society, supports evidence-based policy and legislative solutions designed to eliminate cancer as a major health problem. As the nation’s leading advocate for public policies that are helping to defeat cancer, ACS CAN ensures that cancer patients, survivors, and their families have a voice in public policy matters at all levels of government.
ACS CAN commends CMS for recognizing the importance of ensuring that Medicaid delivers better quality care to the millions of lower income Americans who rely on the program. If done well, managed care has the potential to encourage seamless care, foster integration across sites of care and
collaboration among providers, and utilize technology in ways that help to improve care. Central to the success of managed care in Medicaid is the systematic measurement of success. Only by measuring how well Medicaid plans actually deliver on their promise of better coordinated care will CMS be able to ensure more patient-centered care for Medicaid enrollees.
I. MEDICAID MANAGED CARE
B. Provisions of the Proposed Regulations
1. Alignment with Other Health Coverage Programs a. Marketing (§ 438.104)
CMS proposes to amend the definition of “marketing”. Under the proposal, a qualified health plan (QHP) would be permitted to communication and/or engage in marketing to a Medicaid enrollee even if the QHP also is the entity providing Medicaid managed care plan.
ACS CAN urges CMS to prohibit a QHP issuer from engaging in marketing activities with a Medicaid managed care enrollee or potential enrollee. We are concerned that by allowing such communication to fall outside the scope of marketing materials, it also falls outside the scope of CMS review. Thus, there would be little to no oversight on the content of the information being provided to Medicaid managed care enrollees. This could result in confusion on the part of Medicaid managed care enrollees who may not be made fully aware of their opportunity to choose a different Medicaid managed care plan. We urge CMS to clarify that any marketing materials directed at a Medicaid enrollee or potential enrollee – even those produced by issuers of qualified health plans – be subject to the marketing activities provisions of the proposed rule.
b. Appeals and Grievances (§ 438.400, etc.) (3) General Requirements (§ 438.402)
Level of review: CMS proposes to limit Managed Care Organization (MCO), Pre-paid Inpatient Health Plan (PIHP), and Pre-paid Ambulatory Health Plan (PAHP) to only one level of appeal for enrollees before beneficiaries exhaust the managed care plan’s internal appeals process. After a beneficiary exhausts the internal appeals process, the beneficiary would be able to request a state fair hearing (SFH).
ACS CAN supports this proposal. Many cancer patients must utilize a plan’s appeals process in order to obtain access to products and services necessary for their cancer treatment. Minimizing the levels of a plan’s internal review process will allow a patient more timely access to an external reviewer who can independently evaluate the validity of the patient’s appeal.
Timing of grievances and appeals: CMS proposes to require uniform rules across all states with respect to the timing of filing a grievance or appeal. Currently states are permitted to set a timeframe between 20 and 90 days for an enrollee to file an appeal. CMS proposes to allow grievances to be filed at any time and for appeals to be filed within 60 calendar dates of the receipt of the notice of adverse benefit determination. This timeframe is consistent with Medicare Advantage (MA) and private health plan rules.
ACS CAN supports this proposal. We believe the proposed appeals timeframes will help ensure
consistency across all states. We also support CMS’ proposal to establish appeals timeframes consistent with MA and private health plan rules. This consistency will help minimize confusion as an enrollee transitions into and out of the Medicaid program.
Electronic access: CMS also requests comment on the extent to which states and managed care plans currently are using or plan to implement an on-line system that can be assessed by enrollees for filing and/or status updates for grievances and appeals.
ACS CAN supports the use of electronic access to systems, which has the potential to improve enrollee information and reduce plan administrative costs. However, we are concerned that CMS also should permit an enrollee to file an appeal and/or grievance and check status updates through non-electronic means as well. Many Medicaid beneficiaries do not have 24/7 Internet access.
(4) Timely and Adequate Notice of Adverse Benefit Determination (§ 438.404)
CMS proposes to add a requirement that a plan must notify the enrollee of the reason for the plan’s adverse determination. In addition, CMS proposes that the enrollee must be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information
relevant to the enrollee’s claim for benefits.
ACS CAN supports this proposal. Many cancer patients must utilize a plan’s appeals process in order to obtain access to products and services that may be necessary to treat their cancer, particularly in cases where the cancer may be rare or in an advanced state. Allowing the enrollee notice of reason for an adverse determination will help the enrollee as she works through the appeals process, if necessary.
(5) Handling of Grievances and Appeals (§ 438.406)
CMS proposes to require MCOs, PIHPs, or PAHPs to send an acknowledgement receipt for each appeal. These entities also would have to ensure that individuals making decisions were not involved in any previous level of review or decision making (including a requirement that decision-makers cannot be subordinates of those involved in the previous levels of review or decision-making) and have the appropriate clinical expertise. CMS also added a requirement that decision makers must take into account all comments, documents, records, and other information submitted by the enrollee or their representative, regardless of whether such information was submitted or considered in the initial determination.
ACS CAN supports these proposed changes, which we believe will help to ensure that an enrollee is provided a fair and impartial review of his grievance or appeal.
(6) Resolution and Notification: Grievances and Appeals (§ 438.408 and § 431.244(f))
Timeframe: Currently MCOs and PIHPs have up to 45 days to make a standard (non-expedited appeal). CMS proposes to shorten the timeframe to 30 days in which MCOs, PIHPs, and PAHPs would have to make a decision about an enrollee appeal. In addition, CMS proposes to modify its expedited appeals decision timeframe from 3 working days to 72 hours.
ACS CAN supports these proposed timeframes. Reducing timeframes by which the plan must act on an enrollee’s request for appeal will help ensure that the enrollee can obtain more timely access to a necessary product or service.
Extension: Currently CMS allows the appeal timeframes to be extended by up to 14 days at the enrollee’s request or at the plan’s request provided that the additional information needed during the delay is in the best interest of the enrollee. When the request for an extension is not requested by the enrollee, CMS proposes to require plans to make reasonable efforts to provide the enrollee prompt oral notice and written notice within 2 calendar days. CMS also proposes new standards that would require the appeal to be resolved as expeditiously as the enrollee’s health condition requires and no later than the date that the extension expires.
ACS CAN supports the proposal to allow an enrollee to request an extension of the appeals timeframe. However, we are concerned that CMS’ proposal to allow a plan to extend the appeal timeframe needs additional clarification. As currently written, this proposal could be broadly construed to the benefit of
the plan, and to the detriment of the enrollee who will face a delay in receiving access to the product or service that is the subject of the appeal.
c. Medical Loss Ratio (§ 438.4, § 438.5, § 438.8, and § 438.74)
CMS proposes to implement a medical loss ratio (MLR) standard of at least 85 percent for the rate year beginning January 1, 2017. In the preamble, CMS notes that the goal of developing the MLR standards is to be consistent with the National Association of Insurance Commissioners (NAIC) model and federal regulations pertaining to private market and Medicare Advantage plans.
ACS CAN supports CMS’ proposal. MLR is a powerful tool for assessing the value of actuarially sound premiums, provides consistency in insurance regulation, and ensures transparency and accountability. According to the Kaiser Family Foundation, a majority of states have average Medicaid managed care MLRs at 85 percent or higher.1
CMS proposes to include in the MLR numerator activities that improve health care quality. ACS CAN supports CMS’ proposal, which we believe will help to ensure that plans are incentivized to engage in activities that improve health care quality. We encourage CMS to enumerate specific activities – such as care coordination, case management, and non-emergency medical transportation services – within the text of the regulation (§ 438.8(e)(3)).
2. Standard Contract Provisions (§ 438.3, § 438.6)
Coverage of outpatient drugs: CMS proposes to add a new section that would apply certain rules to MCOs, PIHPs, and PAHPs regarding coverage of covered outpatient drugs that currently apply only to fee-for-service drug coverage. Among other changes, the requirements are intended to ensure that if a drug is not included in a plan’s formulary, the drug can be made available to an enrollee under a prior authorization process.
ACS CAN supports CMS’ proposal, which we believe will help to ensure that enrollees have access to prescription drugs that may not be included on a plan’s formulary. However, we note the regulations do not provide a minimum formulary requirement. We urge CMS to establish such requirements in order to ensure that enrollees have access to prescription drugs that best meets their needs, thus precluding the need for an individual to access the prior authorization process.
Prior authorization timeframe: CMS clarifies the prior authorization requirements, stating that plans are required to provide a response to a request for prior authorization for a covered outpatient drug within 24 hours of the request and dispense a 72 hour supply of the drug in emergency situations.
ACS CAN applauds CMS for including this requirement, which we believe provides an important
consumer protection. Individuals undergoing cancer treatment often need timely access to prescription drugs and a delay could negatively impact a patient’s prognosis.
1
Kaiser Family Foundation found that 28 out of the 36 states for which information was available had an average Medicaid managed care MLR of at least 85 percent. Julia Paradise, Key Findings on Medicaid Managed Care: Highlights from the Medicaid Managed Care Market Tracker, Kaiser Commission on Medicaid and the Uninsured (Dec. 2014), available at http://kff.org/medicaid/report/key-findings-on-medicaid-managed-care-highlights-from-the-medicaid-managed-care-market-tracker/.
5. Beneficiary Protections a. Enrollment (§ 438.54)
Voluntary and mandatory managed care programs: For both voluntary and mandatory managed care programs, CMS proposes that states provide at least 14 days of fee-for-service coverage for potential enrollees to choose a managed care plan.
ACS CAN appreciates CMS’ clarification that individuals receive fee-for-service coverage while they choose their managed care plan. We are concerned, however, that the 14-day requirement provides insufficient time in which an individual can meaningfully make a choice of managed care plans.
Individuals need time to review their coverage options. We note that the health insurance marketplace and the Medicare programs provide a significantly longer timeframe in which enrollees can choose a plan. We strongly urge CMS to adopt a 45-day election period, during which the enrollee will receive fee-for-service coverage.
Enrollment information: In an effort to provide all beneficiaries with information, education, and the opportunity to choose their plan, CMS proposes to require states to develop informational notices that clearly explain the impact of failing to choose a plan (default enrollment).
ACS CAN supports CMS’ proposal. With respect to default enrollment, we urge CMS to require that states take into account any existing provider relationships the enrollee may have, paying particular attention to any specialists or subspecialists who provide care to the enrollee. For example, if an enrollee were currently undergoing cancer treatment, switching oncologists could result in delayed treatment and could be harmful to the individual.
b. Disenrollment Standards and Limitations (§ 438.56)
90-day disenrollment: CMS proposes to change the disenrollment rules to limit disenrollment without cause to the first 90 days of the enrollee’s initial enrollment. Currently, enrollees are permitted to disenroll from a plan every 90 days until potentially all managed care options are exhausted.
ACS CAN opposes this proposal. An enrollee may choose to switch plans for a variety of reasons (e.g., providers may not be accessible via public transportation, the enrollee may wish to see a provider that is not included in a plan’s network, etc.). Allowing enrollees only one 90-day period in which to switch to a different plan takes away an enrollee’s opportunity to utilize a plan that best meets the enrollee’s needs. For example, an enrollee may experience a cancer diagnosis 120 days after enrollment and it may be in her best interest to switch to a different plan that provides better coverage for cancer
treatments. In such instances, disallowing the individual the opportunity to switch plans may negatively impact the individual’s long-term prognosis.
Disenrollment by the managed care entity: CMS would prohibit an MCO, PIHP, PAHP, and PCCM from requesting that an enrollee be disenrolled because of an adverse change in the enrollee’s health status. § 438.56(b)(2). However, CMS would provide an exception when the enrollee’s “continued enrollment in the MCO, PIHP, PAHP, [Primary Care Case Manager (PCCM)], or PCCM entity seriously impairs the entity’s ability to furnish services to either this particular enrollee or other enrollees.” Id.
ACS CAN is concerned this language could be used to discriminate against certain enrollees, particularly high-cost enrollees, such as individuals with cancer. Rather than permitting plans to involuntarily
disenroll an enrollee, we urge CMS to create safeguards that would permit the enrollee to obtain access to medically necessary products and services.
Cause for disenrollment: CMS proposes limited “causes” that would permit an enrollee to request disenrollment in a managed care plan. Specifically, CMS proposes that for enrollees who use Managed Long-Term Services and Supports (MLTSS) services, an enrollee would meet the disenrollment “cause” requirement if “the enrollee would have to change their residential, institutional, or employment supports provider based on that provider’s change in status from an in-network to an out-of-network provider with the MCO, PIHP, or PAHP.” § 438.56(d)(2)(iv).
ACS CAN supports this proposal and strongly encourages CMS to expand this requirement beyond individuals who use MLTSS services. Cancer patients often need access to specialized providers and when those providers are no longer in the network, the patient will likely experience a gap in care which can negatively impact a cancer patient’s prognosis.
c. Beneficiary Support System (§ 438.71)
CMS proposes to require that states develop and implement a beneficiary support system for enrollees. This system would provide choice counseling and assistance for enrollees in understanding managed care and for those who have expressed an interest in Long-Term Services and Supports (LTSS).
ACS CAN applauds CMS requiring states to create a beneficiary support system. However, we note that many individuals with chronic care needs use a caregiver. We strongly urge CMS to require that caregivers are included in the beneficiary support system.
We note that § 438.71(e) provides functions specific to LTSS activities. Many of these requirements also would benefit individuals with chronic care needs and/or who are undergoing specialized treatments such as cancer. Thus, we strongly encourage CMS to expand this section to include other enrollees who may benefit.
We are concerned, however, that the proposed rule fails to provide sufficient detail regarding what plans should be required to provide as part of the beneficiary support system. We urge CMS to require plans to provide care coordination and patient navigation services. Currently, many patient navigation services are covered only with a Medicaid 1115 waiver. We urge CMS to require plans to include patient navigation services as part of the care management benefit.
Care coordination allows for deliberate organizing of patient care, ensuring that the patients’ needs are communicated at the appropriate time and to the appropriate person which in turn allows for safer and more effective care.2 Those features make care coordination extremely important throughout the cancer care continuum. The inclusion of coordinating services between care setting and ensuring discharge planning for short, as well as, long term care is not only more efficient, but cost effective. Readmissions are often caused by the lack of coordination, costing Medicaid $7.6 billion in 20113. A lack of care coordination for cancer patients has been shown to result in lower quality of care for cancer
2
Care Coordination. May 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html.
3
Hines A, Barret M, Jiang J, and Steiner, C. April 2014. Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011. HCUP Statistical Brief #172. April 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf.
patients.4 Better coordination between providers and more seamless transitions of care would save Medicaid dollars and provide cancer enrollees a more coordinated process.
Care coordination works in concert with patient navigation. Patient navigator services should include the delivery of current and customized diagnosis and treatment information that ensures patient understanding and informs decision making; the connection of patients to useful and available
community services; consistent support and monitoring of care plans; and, an overall determination of the needed services to be used to remove barriers to care including transportation, lodging, health insurance, cultural, and language barriers.
Providing for a new enrollee’s needs assessment within 90 days of enrollment would be an integral step in the right direction to address cancer associated issues. This opportunity will allow CMS to identify conditions that when left uncontrolled cause a negative impact on health, as well as increases overall cost. Knowledge gained through the new enrollee’s needs assessment can allow for targeted and early intervention. In cancer this is extremely relevant due to the risk posed by other comorbidities, such as diabetes and heart disease. Medicaid enrollees often experience challenges affecting their health and ability to navigate the health care system.5 Gaps in coverage, literacy level, cultural and communication barriers, deficiencies in transportation, unstable housing, insecure employment, and low socioeconomic status all contribute to poorer outcomes. For these reasons, ensuring focus on care coordination that is broader in scope than primary care is imperative. This is especially relevant throughout the cancer care continuum, as cancer patients and their families face a number of not only medical, but social and economic challenges. To treat the whole patient, Medicaid will have to go beyond physical health. Care coordination will have to encompass services from multiple social support and community providers, addressing behavioral and psychosocial needs to bridge gaps in care.
e. Continued Services to Beneficiaries and Coordination and Continuity of Care (§ 438.62, § 438.208)
CMS proposes to add specific requirements to ensure that enrollees have access to services during transition between plans. The proposed rule would apply continuity of care coverage during a transition “from FFS to a MCO, PIHP, PAHP, PCCM or PCCM entity or transition from one MCO, PIHP, PAHP, PCCM or PCCM entity to another when an enrollee, in the absence of continued services, would suffer serious detriment to their health or be at risk of hospitalization or institutionalization.” § 438.62(b).
ACS CAN supports this proposal and we encourage CMS to broaden this continuity of care provision to also include instances where an individual transitions into the Medicaid program and when an individual transitions from an MCO, PIHP, PCCM or PCCM entity into FFS. We also urge CMS to ensure that
continuity of care provisions are broadened to include instances when a provider – particularly a specialist like an oncologist – leaves the plan’s network.
4
Bowles EJA, Tuzzio L, Wiese CJ, et al. Understanding High-Quality Cancer Care: A Summary of Expert Perspectives. Cancer, 2008; 112(4): 934-942.
5
Hospital Guide to Reducing Medicaid Readmissions: Why Focus on Medicaid Readmissions?. August 2014. Agency for Healthcare Research and Quality, Rockville, MD.
We note CMS’ proposal would extend only to instances where the enrollee would suffer serious
detriment to their health or be at risk of hospitalization or institutionalization. We believe this language would not cover all instances in which continuity of care may be appropriate. We urge CMS to consider revising the standard to instances where discontinuing care by that physician or health care provider would worsen the condition and interfere with anticipated outcomes.
We also urge CMS to broaden this definition to allow individuals who are undergoing a course of
treatment for a serious acute condition to continue to receive care from their initial providers. A serious acute condition would include a disease or condition requiring complex on-going care which the covered person is currently receiving, post-op visit by the surgeon preforming the surgery, such as chemotherapy or radiation therapy.
We are concerned with the proposed language requiring plans only to provide a “best effort to conduct an initial assessment of each enrollee’s needs.” We urge CMS to strengthen this language to require plans to conduct the assessment – not just make a “best effort” to do so.
Finally, we urge CMS to clarify that an individual who transitions between plans is not subject to additional prior authorization and/or step therapy requirements simply because the individual transitioned into the plan. Such requirements can create barriers to care during these periods of transition.
6. Modernize Regulatory Requirements
a. Availability of Services, Assurances of Adequate Capacity of Services, and Network Adequacy Standards (§ 438.206, § 438.207, § 438.68, § 440.262)
CMS proposes to establish standards for states to follow to develop Medicaid managed care network adequacy standards that address medical services, behavioral health services, and long term services and supports. ACS CAN strongly supports CMS’ addition of these new provisions.
Timely access: We note the proposed rule does not include requirements imposing limits on the maximum time an enrollee must wait to see a provider. § 438.68(b)(3). For some conditions, like cancer, a delay in accessing a provider can negatively impact an individual’s treatment options and/or prognosis. We urge CMS to establish requirements to ensure that an enrollee’s wait time to see an in-network provider does not impede the enrollee’s access to care. If a plan is unable to provide the enrollee with access to an in-network provider within a timely manner, then the enrollee should be permitted to access an out-of-network provider who is located geographically proximate to the enrollee. CMS also should consider adding requirements that the state perform periodic assessment of wait times.
Access to out-of-network providers: CMS proposes to require that plans allow an enrollee to obtain services from an out-of-network provider when necessary services are not available from in-network providers. § 438.206(b). ACS CAN supports CMS’ proposal. Individuals with cancer need access to specialized services, which may require the enrollee to seek care from an out-of-network provider, particularly if the cancer requires access to subspecialists. We urge CMS to clarify that in cases where an enrollee needs to access services from a provider who is not within the plan’s network, the plan will arrange for the enrollee to receive care from a geographically proximate provider with the specialized expertise necessary to treat the enrollee’s condition.
b. Quality of Care § 438.334
Accreditation: CMS proposes to a requirement that as a condition of contacting with the state, MCOs, PIHPs, and PAHPs must undergo a review of the basis of performance in accordance with standards as least as stringent as those used by private accreditation entities approves or recognized by CMS. ACS CAN supports CMS’ commitment to ensure that managed care plans are held accountable for the quality of care they provide to their enrollees. However, we are concerned that under the proposal, states could require plans to be held to only certain reporting requirements, which could result in inconsistent reporting across plans. We urge CMS to permit states to accept the accreditation standards used by private accreditation entities in their entirety, as required for Marketplace plans.
Star rating system: CMS proposes to create a star rating system for Medicaid managed care plans, similar to the system used in the marketplace. All consumers – regardless of their source of insurance coverage – need clear, concise and reliable information so that they can make the appropriate choice of a plan that best meets their needs. We commend CMS for its goal of greater quality transparency. We agree with your assessment that a star system similar to that used in the market place makes sense as it provides a more seamless approach for those consumers who move into Medicaid from the marketplace.
At the same time we would caution CMS that a poorly designed quality rating system could actually do more harm than good – not providing beneficiaries with accurate and timely information that could lead them to choose the wrong plan. This would create distrust in the system.
We strongly urge CMS to develop a star rating system with considerable input from the consumer community. The listening sessions outlined in the draft rule are one tool. We urge CMS also to create a consumer advisory committee that can provide input throughout the development of the system.
d. Information Standards (§ 438.10)
CMS proposes a number of requirements related to the information that is made available to current and potential enrollees in Medicaid managed care plans.
Limited English proficiency: It is well documented that limited language proficiency creates barriers to accessing care. The proposed rule would define the term “prevalent” to mean “a non-English language determined to be spoken by a significant number or percentage of potential enrollees and enrollees that are limited English proficient and consistent with the Office for Civil Rights in enforcing
anti-discrimination provisions.” § 438.10(a). We strongly urge CMS to clarify the terms “significant number or percentage” to mean the lesser of 1,000 individuals or 5 percent of the population in the managed care plan’s service area.
Provider contract termination: CMS proposes to require MCOs, PIHPs, PAHPs, and PCCM entities to make a good faith effort to give written notice of termination of a contracted provider within 15 days of the termination of the contract, to each enrollee who received his primary care from, or was seen on a regular basis by, the terminating provider. § 438.10(f)(1). We are concerned that the proposed rule fails to provide sufficient clarity regarding what is meant by the term “seen on a regular basis by”. We urge CMS to provide additional information.
Following successful cancer treatment, a cancer survivor must have periodic appointments with her oncologist. We are concerned that, under the proposed rule, a cancer survivor may not be made aware
if her oncologist were to terminate a contract with the plan. Thus, we urge CMS to ensure that
individuals who received specialized services – such as cancer care – receive notice when their specialist leaves the plan’s network. When a specialist leaves the plan’s network, CMS should require the plan to provide notice to enrollees who have seen the specialist within the past three years. This notice also should inform the enrollee of in-network providers who are accepting new patients.
Provider directories: We are pleased CMS is requiring plans to provide specific information regarding provider directories. We note that some providers may have multiple office locations and appreciate CMS’ requirement that the directory note a provider’s locations, if applicable. We also support CMS’ proposal to require that the directory note whether the provider is accepting new patients. In some instances, providers with multiple locations only may accept new patients at one location and not at all locations. Thus, we urge CMS to clarify that if a provider maintains multiple locations, she must note the extent to which she is accepting new patients at each of her facilities.
Formulary information: CMS proposes to require MCOs, PIPHs, PAHPs, and PCCM entities to make available specific information about the plan’s formulary. ACS CAN supports CMS’ proposal. We also urge CMS to require plans to note whether any drugs on the formulary may be subject to utilization management review edits (e.g., step therapy, prior authorization, etc.). Individuals with cancer often must take specific prescription drugs involved in the treatment of their cancers and may prefer a plan that imposes limited or no utilization management review edits on their specific drugs. CMS also should require plans to provide information to an enrollee regarding the process for obtaining medically necessary drugs that are not included in the plan’s formulary.
g. Non-Emergency Medicaid Transportation PAHPs (§ 438.9)
CMS proposes to limit the scope of standards that apply to non-emergency medical transportation (NEMT) PAHPs.
ACS CAN is concerned with CMS’ proposed policy under which NEMT PAHPs would not be required to have a grievance system in place. We believe that individuals who utilize NEMT PAPH services should have access to a grievance process in order to register a compliant about the quality of services received.
Cancer patients often utilize NEMT services to access cancer screenings, diagnostic, and treatment services. After receiving a cancer diagnosis, one of the most difficult challenges patients face is getting to and from treatment. Oncology practitioners often counsel cancer patients not to drive following treatment because chemotherapy leaves patients fatigued, and some of the medications administered along with chemotherapy tend to make patients drowsy and unable to drive themselves or use public transportation. In addition, many cancer patients – particularly those with low or limited incomes – do not own a vehicle, cannot afford public transportation, or do not live in an area where public
transportation is readily accessible. Often patients do not have a family member or friend who is available to provide regular assistance with transportation. Individuals with cancer need regular access to care and cancer treatment services; when that access is disrupted – as it could be when the
individual lacks transportation to the health care service – the effectiveness of the treatment could be jeopardized and the individual’s chance of survival could be significantly reduced.
NEMT is also used by individuals to obtain access to preventive services, such as cancer screenings. Early detection of cancer generally results in less expensive treatments and better health outcomes.
Further, colorectal and cervical cancer screenings can prevent cancer by detecting and removing pre-cancerous lesions. However, lack of transportation to screening services hinders an individual’s ability to obtain the necessary screening and thus for some individuals could result in detection of cancer at a later stage.
Conclusion
On behalf of the American Cancer Society Cancer Action Network we thank you for the opportunity to comment on the proposed rule implementing changes to the Medicaid managed care program. If you have any questions, please feel free to contact me or have your staff contact Anna Schwamlein Howard, Policy Principal, Access and Quality of Care at [email protected] or 202-585-3261.
Sincerely,
Christopher W. Hansen President
